Guest post by Mark S. Courey, MD, Chief of the Division of Laryngology and Director of the Grabscheid Voice and Swallowing Center of Mount Sinai at the Mount Sinai Health System. To make an appointment with Dr. Courey, call 212-241-9410.
Professional Voice Care: Why Is It So Important for Laryngologists, Speech Language Pathologists and Trainers to Work Together?
We all use our voices differently. From vocal performers to computer programmers, we communicate vocally to fulfill professional and social obligations. Just as golfers retain muscle memory from swinging a club, we develop patterns of voice use. But if swinging a golf club becomes tiresome, we can choose to put it down. Although vocal communication may become tiresome, many of us cannot—and would not—choose to cease speaking. Our voices inform first impressions; usage and tone are intrinsic to the individual. Judgment of this very personal trait can make us nervous.
Causes of Voice Disorders and Trauma to the Vocal Folds
Most voice problems can be attributed to vocal use patterns. These patterns are a combination of how often and how loudly we use our voice. How often is typically a choice, but volume depends on the situation. If we are speaking to a colleague when outdoors, battling the background noise of a busy city, we must raise our volume much more so than if chatting in a quiet room with a small group. Often, but not always, we can control the situation. However, if our job or a social situation requires us to speak loudly, we must learn to do so efficiently.
If we produce vocal volume inefficiently, or just talk too much, we can traumatize the surface skin of the vocal folds. To produce sound, air is blown through the vocal cords, forcing the skin of the vocal cords to vibrate. Although necessary for speech, this vibration, even when done efficiently, is slightly traumatic. When most of us begin to feel this sense of fatigue, we stop speaking and allow our vocal cords ample time to heal. Overuse, or speaking at excessive volumes, due to work or social situations, can produce trauma that does not allow the vocal folds to heal properly. This results in the formation of bumps, lumps, or scar tissue on the vocal fold. Much like the development of a corn or callous when wearing ill-fitting shoes, a health professional can remove the scar tissue, but, if we do not change the shoe that created the problem the corn or callous will return. This is a critical point. Sometimes if we change the shoe, the troublesome callous will go away on its own.
Importance of Voice Experts Working Together
I hope these analogies clarify why laryngologists, vocal trainers, and speech-language pathologists (SLPs) must work together to treat patients with vocal problems. The Grabscheid Voice and Swallowing Center of Mount Sinai in New York uses a team approach, providing patients with a comprehensive evaluation. Patients will see a physician to evaluate the structure and function of the larynx and help provide a diagnosis, and a vocal trainer and SLP to devise an efficient vocal pattern based on the structure and function of the patient’s vocal folds and vocal requirements. This collaboration greatly benefits patients, offering multiple approaches for tackling their vocal problems.
Change in vocal function is dictated by results from the physician’s examination; voice use demands are directed by both the SLP and vocal trainer. Changes in voice use patterns should occur simultaneously with the patient is improving his or her lifestyle by reducing overall voice use and volume, adjusting the diet to restrict irritants and foods that cause reflux, and avoiding smoky or dry environments. Often, just by changing vocal use patterns and habits, any problems with the skin of the vocal folds or the voice will improve. In my experience, if patients can improve their efficiency of use, improvements in the voice and vocal folds will occur within 6 to 12 weeks. If the vocal folds do not heal in this period, surgery can be considered.
Consideration of Vocal Fold Surgery
There are two possible reasons why vocal improvements do not occur. Either the patient cannot make the changes in vocal efficiency or the vocal fold damage is too severe to respond to changes in usage. This is the only case in which surgery should be considered. The entire team—patient, vocal trainer, SLP, and physician—needs to understand what each can do to help improve the voice. In my experience, in cases where surgery is considered, there is a high likelihood of recurrence (50-80 percent) if the patient does not change their patterns of voice use prior to surgery. Therefore, it is of utmost importance that the entire team acknowledges the high rate of recurrence and works together to minimize these risks. Our team’s goal is to provide patients with as many voice use options as possible and to restore voices to their natural tenor for the remainder of their life.